"As the most widely used class of prescription drugs for osteoporosis, this suggests limited awareness among clinicians regarding optimal bone health management," they wrote.

Canadian guidelines have recommended bisphosphonates for men on ADT since 2006 because the prostate cancer therapy carries adverse effects including bone loss and increased fracture risk. Since 2002, Canadian guidelines also have generally recommended bisphosphonates for men with osteoporosis or fragility fracture.

To assess whether bisphosphonates were being used as recommended in this population, Alibhai and colleagues looked at data on 35,487 men, ages 66, and up from the Institute for Clinical Evaluative Sciences in Ontario and the Ontario Cancer Registry, who had ADT for prostate cancer between January 1995 and December 2012.

Bisphosphonate prescription claims in this population did rise over time, but rates were still low by the end of the study period, jumping from 0.35 per 100 in 1995-1997 to 3.40 per 100 in 2010-2012 (P<0.001).

Rates were higher among men with prior osteoporosis, rising from nearly nothing at study start to nearly 10 per 100 in 2010-2012. But rates of bisphosphonate prescriptions remained low even among men with prior fragility fracture, the researchers said.

Peak bisphosphonate claims occurred in 2007-2009, at about five per 100, and these were highest among men with prior osteoporosis at 11.89 per 100.

The fact that rates fell after that time point may have had to do with media reports about the association of bisphosphonates with rare side effects such as osteonecrosis of the jaw and atypical femoral fractures, the researchers said.

"This is appropriate for groups at low risk for fractures, but the decrease in use for high-risk patients is concerning," they wrote, concluding that it's "reasonable that most men with prior osteoporosis or fracture should be taking a bisphosphonate or other effective bone medication."

The study was supported by Toronto General Hospital and the Toronto Western Hospital Research Foundation.

Alibhai and most co-authors disclosed no relevant relationships with industry. One co-author disclosed relevant relationships with Merck and the Canadian Institutes of Health Research.

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